Bermuda shorts 9: finding a way

by Bill Shields

28 September 2018

In April 2017, after 30 years working in NHS finance, former HFMA chairman Bill Shields moved to Bermuda as chief financial officer of the territory’s hospitals board. In this series of blogs, he documents his experiences.

Howdy y’all. As you can probably guess, I’ve spent a considerable part of the last two months in the US and so this edition will probably read more like a travelogue than usual. 

First, as I mentioned last time, I’ve been in San Francisco (where, despite Mark Twain insisting the coldest Winter he ever spent was there in July, yours truly managed to get sunburned) and then on a cruise to Alaska. This was definitely a bucket list item for Avril and I and, while we didn’t see any bears, the whales, dolphins and wild salmon more than made up for it.

Add to that, being able to see a glacier ‘calving’ where huge blocks of ice break off and turn into icebergs, and it really is a destination I’d recommend to anyone. The downside, for me, was being on a cruise ship for days at a time between destinations – there is only so much you can eat and drink and only so many quizzes and games of bingo you can play!

Later in August, we visited Boston (less than two hours away) to celebrate our wedding anniversary in an attempt to get away from the heat and humidity of Bermuda. Bizarrely, we arrived on the hottest ever recorded day with a high of 98 degrees! Again, this is a destination I would thoroughly recommend, not only for the city itself, but also the opportunity to explore Massachusetts and New England beyond. We visited Salem (home of the infamous witch trials) and took a train and ferry to Martha’s Vineyard, which was definitely one of the high-points of this summer.

Finally, I have actually done some work since last time! You will recall I talked about the process Bermuda Hospitals Board (BHB) was following to establish a clinical affiliation agreement with a US hospital or health system. This is absolutely necessary in Bermuda as we are an island, some 600 miles from land and unable to offer the full range of secondary and none of the tertiary care services required by the population.

Following an extensive procurement process, BHB has chosen Johns Hopkins Medicine (JHM) to be its clinical affiliate. JHM is a large academic health system based in Baltimore, Maryland, but with affiliates in Washington DC, Florida and elsewhere in the US, as well as across the world. The organisation has revenue turnover of $8bn, employs 43,000 people, has a major focus on research and education and has delivered a number of healthcare firsts including use of surgical gloves and the development of both renal dialysis and cardiopulmonary resuscitation (CPR).

While we saw many innovative practices, there are a few that I think are worth noting given they show how a non-NHS provider has addressed similar challenges to those faced in the UK. These practices include: JHM’s creation of a command centre; the development of interventional radiology as a standalone surgical specialty; and the development of non-invasive medical bariatric procedures.

The capacity command centre has been co-created between JHM and GE Healthcare Partners and is a comprehensive computerised system that assists patient flow. Many of you, like me, will be really pleased when we are able to produce a statistical process control chart showing whether variation in flow is within an acceptable confidence interval, or not. So I can honestly say I was blown away by what I saw – an ‘operations room’ with real time information shown on flat screen monitors (referred to as tiles).

Anything requiring action was flagged up until dealt with. The 60 staff responsible for admissions, bed management, patient flow and discharge were co-located and, crucially, decisions were supported by a sophisticated simulation model that utilises artificial intelligence to ensure it improves its forecasting ability as it runs simulations.

Watching this in operation, I saw an instance where medicine beds were in negative balance – something that happens in Bermuda and in the NHS and almost always provokes a reactive response. The simulation indicated that, based on known information (live bed state, accurate elective activity and actual discharges) and predictions around non-elective admissions, predicted length of stay and discharges, this would be deliverable. I have never seen anything like this before.

Equally, interventional radiology (IR) is way beyond the typical NHS service offering. The service provides care at the bedside including freezing and removal of cancerous tumours and is epitomised by its mission statement borrowed from Hannibal – ‘where there is no way, we find a way’.

Finally, continuing the theme of using non-invasive procedures, we received a presentation on the non-invasive bariatric service. Led out of the medical division by a gastroenterologist, this utilises non-invasive endoscopic techniques to either suture the gut and reduce its capacity to absorb food, insert a balloon to restrict the size of the stomach, or use Botox to paralyse the muscle wall in the gut and, again, reduce its ability to absorb calories. Early results have shown success rates comparable to bariatric surgery, reduced rehabilitation times as well as pre-operative time and delivered at least 30% savings in costs. Clearly, living in a country where 34% of the population is overweight and long-term conditions such as diabetes, dialysis, chronic heart failure and stroke are increasing at an alarming rate, this is of great interest.

Having worked in an academic health sciences centre, I have heard a lot about translational research in the past. I have to say, however, that this is the first time I have seen the pursuit of excellence, research for a clear purpose and benefit and the relentless determination to find solutions through scientific inquiry being utilised across an entire organisation, rather than in isolated pockets of best practice. This is, surely, something we can all embrace and learn from.

Until the next time, good day.

Read our other 'Bermuda shorts' blogs here:

Bermuda shorts 1: the heat is on
Bermuda shorts 2: a collection of firsts
Bermuda shorts 3: putting the focus on costs
Bermuda shorts 4: dark and stormy
Bermuda shorts 5:lost in the triangle
Bermuda shorts 6: flying a kite
Bermuda shorts 7: end of the beginning
Bermuda shorts 8: howzat!